Cognitive skill training improves memory, function, and use of cognitive strategies in cancer survivors

Background Cancer survivors commonly report symptoms of impaired cognition. This project examined effectiveness of a behavioral skills training intervention to improve cognition and reduce cognitive dysfunction symptoms in cancer survivors. Methods Participants were randomly assigned to group-based workshops focused on learning new cognitive skills (skills treatment—TX) or an active control of education workshops (education control—EC) or a passive control of wait list (WL). Participants were evaluated pre- and post intervention with subjective mood and symptom questionnaires and objective neurocognitive tests. Results One hundred twenty-eight participants (mean age 59 years), average 4.6 years (+/− 5.5 years) post cancer treatment with various cancer types (breast, bladder, prostate, colon, uterine), were enrolled. Analysis of all participants who attended workshop(s) revealed improvement in the TX group on all objective cognitive measures (attention, concentration, declarative, and working memory) save one test of selective attention, and improvement on a single measure (verbal memory) and decline (selective attention) in the EC group. TX group also improved on all symptom and mood measures, compare to EC group which improved on a single subscale of a symptom measure, but increased on an anxiety measure. TX group alone improved on a quantified measure of each participants’ unique, “top three,” self-described cognitive symptoms. Conclusion Improvement from behavioral skills training was evident from objective cognitive tests, subjective symptom measures, and quantified, individual patient-specific symptoms. Behavioral skill training is an effective treatment for cognitive dysfunction in cancer survivors, and should be considered as a treatment option by health care providers.

higher score indicates a stronger belief of growth versus fixed mindset toward cognitive abilities such as memory, attention, learning and intelligence.
RTQ-Readiness for treatment questionnaire (RTQ), was adapted from measures related to psychotherapy treatment and refined to apply toward treatment related to cognitive symptoms, to characterize the particular stage of change or readiness for change and treatment. (8) Participants rate statements about need for change and cognitive symptom severity on a likert scale (disagree to agree). Items are scored with a final assignment of one of three categories (pre-contemplation, contemplation or action) according to highest score.
Other questionnaires-and Treatment Fidelity and Adherence Measures. Copies of these measures can be found at https://osf.io/y83bd/ Workshop satisfaction: 'post_treatment_questionnaire' A questionnaire on satisfaction with the workshops, which was given at the final workshop session. Treatment Fidelity: "participant_eval_of_instructor'. Participants were given a questionnaire at the end of each workshop session, that asked participants to rate on a likert scale the degree to which the workshop leader, covered the content for that day's workshop. Question also asked how well the participant comprehended the content.
Adherence: 'instructor_rating_of_participant_effort'. Workshop instructors rated participants on a likert scale according to how well they reported using and applying the workshop material, as well as their impression of participation and effort in the workshops and for homework.

Repeat measures:
Symptom Measures: FACT-Cog. Functional Assessment of Cancer Therapy-Cognition (FACT-Cog) (9) . The FACT-Cog measures frequency and interference of cognitive symptoms. It has three subscales: symptoms of perceived cognitive impairments with higher indicating fewer symptoms, perceived cognitive abilities in which a higher score indicates a rating of better cognitive abilities, and overall quality of life with a higher score indicating better quality of life as it relates to cognition.
Top Three Cog. Symptoms: Each participant is asked to write a description of their top three, most bothersome cognitive symptoms. For each cognitive problem they indicated on a likert scale, frequency (never to several times a day) and interference (not at all to very much). Higher scores indicate more severe and more frequent occurrence of the cognitive symptoms. A copy of the questionnaire and samples can be fount at: https://osf.io/y83bd/ PHQ-9: The Patient Health Questionnaire (PHQ-9) a measure of depression symptoms, for which a higher score indicates more symptoms of depression (10) . BAI: Beck Anxiety Inventory (BAI), an anxiety symptom measure in which a higher score indicates endorsement of more and/or more severe anxiety symptoms. (11) FACIT-fatigue: Functional Assessment of Chronic Illness Therapy -Fatigue (FACIT-Fatigue), measures fatigue symptoms, with higher scores indicating a better quality of life and fewer fatigue symptoms (12) AFI: Attentional Function Index (AFI) a measure of attention and distraction that was developed for use with cancer patients, with higher scores indicating better attention. (13) There are three AFI subscales: interpersonal effectiveness (IE) relates to control from distractions, effective action (AE) relates to multi-tasking, and attentional lapses (AL) relates to instances of lost attention.
MMQ: Multiphasic Memory Questionnaire (MMQ) a comprehensive measure of memory that includes a subscale of use of memory strategies. Only the strategy subscale of this measure was included to determine the degree to which participants utilized memory strategies. Higher scores indicating more frequent use of memory strategies and aids. (14) . SF-36: SF-36 health survey, a general quality of life measure that contains subscales of general health, limitations of activities, physical health, emotional health, social activities, pain, energy and emotions, and social activities along with a total score with higher scores indicating better functioning. (15) PAOF: The patient's assessment of own functioning (PAOF) a measure of perceived disability relating to cognition, with subscales of memory, language-communication, hands, sensoryperceptual, and higher-level cognitive functions with higher score indicating more problems and lower score fewer problems. The memory subscale was used. (16) Objective Cognitive Measures: The neurocognitive battery was comprised of standard objective measures of attention, memory, and executive function, and use of alternate test versions was used. The test battery was given at all study visits (1, 2, 3 and for some participants visit 4). (17) .

WAIS-3-Subscales: Wechsler Adult Intelligence Scale -III(WAIS-III)
Digit Span: Digit span is a task of attention and working memory and involves hearing a series of digits and recalling them in the same order (forward) or in the reverse order (backward). A score is given for both forward and backward and a total score is generated with a higher score indicating better performance.
Letter number sequencing: Letter-number sequencing a task of attention and working memory, participants listen to a random sequence of numbers and letters and must reply with the same information given in numerical and alphabetical order.
Digit symbol: Digit symbol is a task of psychomotor coordination, visual tracking, and working memory and involves rapid completion of a series of symbols according to a visible key, with higher scores indicating better performance.
Stroop: Stroop test, a task of executive function, involves reading text, naming color blocks and the interference trial in which the pre-potent response of reading must be inhibited to name ink color. Time to complete is recorded so that a lower score is better performance (18) .
RAVLT-R: The Rey Auditory Verbal Learning test revised (RAVLT-R), is a task of verbal memory in which participants hear a word list and must recall it after several presentations and a short delay (19) . A modified version of this test was used in which only three learning trials were administered, followed by the interference trial, immediate recall and delayed recall. Total recall across trials as well as the delay are recorded with a higher score indicating better verbal memory.
Story Recall: To measure contextual verbal recall (i.e., story recall) participants listened to a short story, and recalled the story immediately and after a 30 minute delay. The amount of information recalled from the story was scored using a standardized scoring method, with a higher score indicating better recall. For visit 1, participants were given part a of Wechsler Memory Scale-Revised Logical memory (20) and subsequent study visits included alternate paragraphs developed by Sullivan et al. (21)